Provider Demographics
NPI:1669176210
Name:MCKINNON, SANDRA RUTH (LICENSE)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:RUTH
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:LICENSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33200 SCHOOLCRAFT RD STE 111
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1643
Mailing Address - Country:US
Mailing Address - Phone:734-419-1753
Mailing Address - Fax:
Practice Address - Street 1:33200 SCHOOLCRAFT RD STE 111
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1643
Practice Address - Country:US
Practice Address - Phone:734-419-1753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501002253225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist